MEDICARE BASICS

Medicare is a federal program – administered through the Centers for Medicare & Medicaid Services (CMS) – that provides health insurance coverage to eligible older adults and disabled individuals without regard to income level.

To qualify for Medicare, you must be a U.S. citizen or permanent resident and one of the following:

  • 65 years or older.
  • Under 65 with a disability and have received Social Security Disability Insurance for 24 months.
  • Have end-stage renal disease, a permanent kidney failure requiring dialysis or a kidney transplant.

Note: The above requirements are only general guidelines. Visit the Medicare Rights Center and Medicare.gov for more detailed guidelines.

Parts of Medicare

Medicare is broken down into four main parts – A, B, C and D.

Part A (hospital insurance) covers most medically necessary hospital, skilled nursing facility, home health and hospice care. It is free if you have worked and paid Social Security taxes for at least 50 calendar quarters (10 years). If you haven’t worked that long or you’ve paid taxes for less time, you will pay a monthly premium.

Part B (medical insurance) covers most medically necessary doctors’ services, preventive care, durable medical equipment (e.g. oxygen equipment), hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services. You pay a monthly premium for this coverage. Relevant to PH: IV medications are covered under Part B.

Part C (Medicare Advantage) allows private health insurance companies to provide Medicare benefits. Medicare private health plans must offer at least the same benefits as Original Medicare (those covered under Parts A and B), but can do so with different rules, costs and coverage restrictions. Some Medicare Advantage plans also include prescription drug coverage, allowing an individual to pay a single premium for all coverage rather than separate premiums for Original Medicare and Part D. Some Medicare Advantage plans cap the amount that an individual pays out of pocket each year (an out-of-pocket maximum).

Part D (prescription drug coverage) covers drug benefits for anyone with Original Medicare. If you want to get this coverage, you must choose and enroll in a private prescription drug plan.

Some Medicare recipients purchase a Medicare Supplement or Medigap policy to cover health care expenses that Medicare Parts A and B don’t cover. Medigap policies can be combined only with Medicare Parts A and B, not with Medicare Advantage (Part C)

Enrolling in Medicare

If you already get benefits from the Social Security Administration (SSA) or the Railroad Retirement Board, you don’t need to do anything to enroll. You automatically are entitled to Parts A and B starting the first day of the month that you turn 65. Your Medicare card will be mailed to you about three months before you turn 65.

If you don’t receive Social Security, Railroad or disability benefits, you must apply to the SSA. Visit your local Social Security office or call the SSA at 800-772-1213 to sign up. The SSA can answer any questions about your application.

You can apply for Medicare up to three months before you turn 65, but no later than three months after your birthday month. This is known as the Initial Enrollment Period (IEP).

The IEP is a seven-month period to enroll without penalty when you become eligible for Medicare. If you wait until you are 65, or sign up during the last three months of your initial enrollment period, your Medicare Part B start date will be delayed.

If you don’t enroll during the IEP, you can enroll during the General Enrollment Period (GEP) from Jan. 1-­March 31.

Keep in mind that you may face a penalty for each year you were unenrolled. You pay the penalty for as long as you are covered by Medicare. You also can adjust your Medicare plan during the GEP after you enroll.

The Special Enrollment Period (SEP) is a period to enroll without penalty if you initially refused Medicare because you were covered by other insurance when you first became eligible. The SEP extends to any time while you have group coverage, eight months after you lose your coverage or when you (or your spouse) stop working.

Making Adjustments to Your Current Plan

You can adjust your current plan or change plans without incurring a penalty during the Fall Open Enrollment Period (also known as the Annual Coordinated Election Period, or ACEP). Fall Open Enrollment is Oct. 15–Dec. 7 every year. Enrollments and changes made during this period become effective Jan. 1.

Find a Plan That Works for You

When enrolling in Medicare, make sure you find a package that meets your medical and financial needs. Whether it’s a Part D prescription plan or a Medigap supplemental plan, you will want to do research beforehand.

Medicare’s plan comparison tool can be a helpful resource.

Learn more about finding a Medicare Part D plan.

Visit the Medicare Interactive Center for more information on navigating Medicare.

Will Medicare cover my PH medications?

Mary Knabe, RN, MSN